HMO plan members do not have out-of-network benefits, except for emergency or urgently needed services. If they see an out-of-network provider for a non-urgent or emergent need, they may be responsible for the full cost of their care.

HMO-POS Members:

HMO-POS plan members can see any provider who accepts Medicare. However, members have a higher cost share if they receive care outside of the plan’s Medicare Advantage network. Providers who are not contracted with Premera Blue Cross Medicare Advantage can bill Premera Blue Cross directly.

Enrolling in our care management program is easy. Your patients can enroll on their own or can get assistance by phone (with you or a registered nurse). You can also fax the Care Management Referral Form found on the Premera Medicare Advantage website to 855-339-9713.

We encourage you to schedule your Premera Medicare Advantage patients for enhanced annual wellness visits. This Medicare benefit—the visit is free—is a great chance for you to have a discussion with your patients about any health concerns they may have and they can get their questions answered.

Here are some FAQs about the wellness visits.

What is an enhanced annual wellness visit?

The enhanced annual wellness visit is an opportunity for you to meet with your patients to assess their chronic conditions and overall health and wellness. This is a free visit that’s part of their preventive benefit and is reimbursed at a higher rate than a traditional Medicare physical.

Because the enhanced annual wellness visit includes a routine physical, the patient doesn’t have to come in twice for essentially the same type of visit.

We also request that you perform a "condition-pertinent" exam. For example, if the patient has chronic obstructive pulmonary disease, then listen to the patient’s lungs. If the patient has diabetes mellitus, check the patient’s feet. And, for patients with multiple issues, cover areas relevant to those conditions.

How do I bill for an enhanced annual wellness visit?

Submit a claim with G0438/G0439 through your normal claims submission process. If you complete a chronic condition assessment of two or more conditions, include S0250 in addition to the G code. To receive payment, please fax supporting chart notes to 855-348-9135.

What needs to be done to qualify for billing the S code?

To qualify for billing the S code, you must document and assess at least two chronic conditions, including management, evaluation, assessment, and treatment.

Do I need to fax a chart note to Premera?

Yes, for each enhanced annual wellness visit, we need a copy of the chart note faxed to 855-348-9135. We’ll pay the enhanced rate if a chronic condition assessment is done. Alternative options for chart note submission are available, such as remote EMR access, FTP sites, or secure email. Please call your provider network executive if those options work better for you.

What does Premera do with the patient chart note?

We’re required to retain records that support the codes billed. We’ll submit the chart note to Medicare in case of a Risk Adjustment Data Validation Audit.

Does Premera allow an evaluation and management (E&M) visit with an annual wellness visit?

We do not allow an E&M visit with the G0438/G0439. We do allow S0250 for the chronic condition assessment, which adds an additional 3.0 RVU to the visit. If you bill an additional E&M code, the visit is no longer free for the patient. This often causes confusion in the Medicare population; Premera wants to ensure that the visit is free for our members.

If you feel there are conditions that need additional treatment, you’ll need to schedule a follow-up visit on another day.

Can the patient also have a physical in addition to the annual wellness visit?

The Premera annual wellness visit already includes a routine physical.

Does Premera have a template for the annual wellness visit?

Yes. You can download a pre-populated template (either a one-page summary or full version) via onehealthport.com for each patient, based on the information we currently have available. The template includes:

Known chronic conditions

Medications

Recent procedures

Additional treating providers

Can the provider bill the G0438 or G0439 on one day, and then bring the patient back to for a chronic conditions assessment and bill the S0250 on another day?

No, because the S0250 is considered an add-on code for G0438/G0439 and can’t be billed independently.

Does Premera cover the G0402—the Welcome to Medicare visit?

Premera pays G0402–initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. This is sometimes called the Welcome to Medicare visit. The S-code is not available for billing with this visit.

Premera encourages the additional benefit of an enhanced annual wellness visit G0438/G0439 in place of G0402. If the provider does a chronic condition assessment, it’d be appropriate to bill S0250, which encompasses a much more comprehensive visit for the member.

Who is Matrix Medical Network?

Matrix Medical Network is a group of nurse practitioners whom Premera has contracted with to perform annual wellness visits in the patient’s home environment or nursing facility. Each visit includes a limited physical exam, complete review of prescription and over-the-counter medications, and health history discussion. Matrix takes the time to talk to patients and identify gaps in care that can be shared with the health plan and primary care provider (PCP). The visit usually lasts 60 to 90 minutes. The post-visit summary is provided to the PCP.

Can a patient see their own PCP after the Matrix visit?

Yes. Premera supports the PCP-to-patient relationship. Matrix is a collaborative partner, not a PCP replacement.